Cervical Radiculopathy: Classic Case?

History

The patient is a 45-year-old male. He has a 3-month history of left neck, shoulder, and arm pain. His pain radiates through his radial forearm to his thumb and first finger.

Examination

The patient's neurological examination revealed 4/5 strength in the left bicep, decreased bicep reflex on the left, and decreased pinprick in the thumb and first finger.

Prior Treatment

Previously, the patient tried narcotic analgesics, massage, physical therapy, and chiropractic care. These nonsurgical treatments did not bring pain relief.

Images

Figure 1: Axial MRI C5-C6. Left central and foraminal disc herniation is noted.

Figure 2: Sagittal MRI. Disc herniation is noted at C5-C6.

Diagnosis

Herniated disc at C5-C6.

Selected Treatment

Minimally invasive anterior cervical discectomy with fusion at C5-C6.

Figure 3. Post-operative lateral x-ray.

Figure 4. Post-operative PA x-ray.

Outcome

The patient experienced immediate pain relief. His strength and sensation returned over a 6-week period.

Case Discussion

Todd Albert, MD
James Edwards Professor & Chairman of Orthopaedic Surgery
Jefferson Medical College, Thomas Jefferson University
Philadelphia, PA

This case represents a classic presentation and the expected result for surgical treatment of a herniated disc with cervical radiculopathy. I am slightly surprised by the description of symptoms and findings, as I would expect a C6 radiculopathy with a herniation at C5-C6. This typically presents with pain as described into the neck, arm, and thumb/first finger. Patients also present with classic wrist extensor weakness, although bicep weakness can be seen.

Of the options presented, I believe there is good evidence now for choosing one of three options for this patient:

1) Anterior cervical discectomy and fusion
2) Laminoforaminotomy and discectomy
3) Anterior Cervical discectomy and disc replacement

All have shown excellent and durable results in terms of pain relief, neurological recovery, and a very acceptable complication rate. I think there is less evidence to support equivalent results for the other options listed.

Finally, I would note that it is redundant to call the procedure a minimally invasive anterior cervical discectomy and fusion, as the original procedure as described is through a minimal aperture with little tissue disruption and no muscle destruction. The x-ray looks good, but I do have concerns that the plate is very close to the disc space above, which can increase the risk of adjacent segment ossification.

 

Gerard J. Girasole, MD
Orthopaedic Spine Surgeon
Orthopaedic & Sports Medicine Center
Trumbull, CT

The patient is a 45-year-old male with a C6 radiculopathy for 3 months. He has a herniated nucleus pulposus at C5-C6, which is more foraminal than paracentral. He appears to have large foramina.

The only treatment not tried appears to be a foraminal epidural. I would consider offering a patient, without gross or progressive neurological findings, who has not responded to physical therapy and medications after 3 to 4 weeks, an epidural. In this case, if the patient did not respond favorably to the epidural, then my treatment choice would be either an ACDF at C5-C6 or total disc replacement. I would like to see plain films to decide which procedure is the better choice.